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Zorluk: OrtaEstablishing Priorities

The nurse on an inpatient medical-surgical unit is planning initial care for a group of assigned clients. Which client should the nurse evaluate first?

  1. A
    A client with acute pancreatitis who is restless, reports abdominal pain rated as 9 on a 0 to 10 scale, and requests intravenous analgesia.
  2. A client with cirrhosis and esophageal varices who is frequently swallowing and has a resting heart rate of 118 beats/min.Cevap
  3. C
    A client with stage 4 chronic kidney disease who has a morning serum potassium level of 5.2 mEq/L and a creatinine level of 3.5 mg/dL.
  4. D
    A client with a right tibia fracture in a cast who reports localized itching and has a capillary refill time of 2 seconds in the right toes.

Cevap

The client with cirrhosis and esophageal varices who is frequently swallowing and has a resting heart rate of 118 beats/min.
The correct answer identifies the client at highest risk for rapid deterioration. Esophageal varices are fragile and prone to rupture. Frequent swallowing (often indicating blood pooling in the back of the throat) combined with an elevated heart rate (a compensatory response to volume loss) are hallmark early signs of active hemorrhage. This constitutes an immediate circulatory emergency that takes highest priority.

Adım Adım Çözüm

1
Analyze the clinical presentation of each client to distinguish between expected disease manifestations and unexpected complications.
The clients with pancreatitis, chronic kidney disease, and a fractured tibia exhibit expected or stable baseline findings. The client with cirrhosis exhibits new, unexpected findings.
Prioritization requires identifying which client is experiencing an acute change in status.
2
Apply the Airway-Breathing-Circulation (ABC) framework to the unexpected findings.
Frequent swallowing and tachycardia in the presence of esophageal varices strongly suggest active bleeding (a Circulation and potential Airway issue).
The ABC framework dictates that immediate threats to circulation and oxygenation take precedence over all other physiological or comfort needs.
3
Compare the severity of the clients' needs.
Active hemorrhage outprioritizes severe pain, chronic stable laboratory abnormalities, and normal post-fracture findings.
Life-saving interventions must be implemented before addressing symptom management or expected chronic conditions.

Anahtar Kavram

Prioritization using the ABC framework and identifying acute, life-threatening complications over expected findings.
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Establishing Priorities

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